Women's Neurology [Illustrated]

Citation preview

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Women’s Neurology

What Do I Do Now? S E R I E S C O -​E D I TO RS-​I N-​C HIE F

Lawrence C. Newman, MD Director of the Headache Institute Department of Neurology St. Luke’s-​Roosevelt Hospital Center New York, New York Morris Levin, MD Codirector of the Dartmouth Headache Center Director of the Dartmouth Neurology Residency Training Program Section of Neurology Dartmouth Hitchcock Medical Center Lebanon, New Hampshire

OTHER VOLUMES IN THE SERIES Headache and Facial Pain Peripheral Nerve and Muscle Disease Pediatric Neurology Stroke Epilepsy Neuro-​ophthalmology Neuroimmunology Pain Neuroinfections Emergency Neurology Cerebrovascular Disease Movement Disorders Neurogenetics Neurotology

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Women’s Neurology

Edited by

M. Angela O’Neal Department of Neurology Harvard Medical School Brigham and Women’s Hospital Boston, Massachusetts

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2017 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. CIP data is on file at the Library of Congress ISBN 978–​0–​19–​060991–​7 This material is not intended to be, and should not be considered, a substitute for medical or other professional advice. Treatment for the conditions described in this material is highly dependent on the individual circumstances. And, while this material is designed to offer accurate information with respect to the subject matter covered and to be current as of the time it was written, research and knowledge about medical and health issues are constantly evolving and dose schedules for medications are being revised continually, with new side effects recognized and accounted for regularly. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The publisher and the authors make no representations or warranties to readers, express or implied, as to the accuracy or completeness of this material. Without limiting the foregoing, the publisher and the authors make no representations or warranties as to the accuracy or efficacy of the drug dosages mentioned in the material. The authors and the publisher do not accept, and expressly disclaim, any responsibility for any liability, loss, or risk that may be claimed or incurred as a consequence of the use and/or application of any of the contents of this material. 9 8 7 6 5 4 3 2 1 Printed by WebCom, Inc., Canada

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Contents

Preface  ix Contributors  xi SECTION 1. I SSUES IN WOMEN DURING TH E I R REPRODUCTIVE YEARS 

1. Hormonal Contraception in a Woman with Headache  3 M. Angela O’Neal 2. A Young Woman with Jerking Movements  9 M. Angela O’Neal 3. Headache  15 Regina Krel and Paul G. Mathew 4. Seeing Spots  19 Regina Krel and Paul G. Mathew 5. Seizures Occurring Once a Month  25 M. Angela O’Neal 6. Multiple Ovarian Cysts in a Woman with Epilepsy  29 M. Angela O’Neal 7. Newlywed with Headache, Morning Sickness, and Subjective Right-​side Weakness  33 Na Tosha N. Gatson and Terri L. Woodard 8. Routine Long-​Term Epilepsy Follow-​up  39 Na Tosha N. Gatson 9. A Young Woman with Infertility  45 Alexandra Lovett and Whitney W. Woodmansee 10. A Woman with Weight Gain and Fatigue  51 Alexandra Lovett and Whitney W. Woodmansee 11. A 27-​Year-​Old Woman with Epilepsy Planning for Pregnancy  55 P. Emanuela Voinescu

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SECTION 2. PREGNANCY 

12. What Imaging Test Do I Order?  63 M. Angela O’Neal 13. A Lady with a Headache in the First Trimester  67 M. Angela O’Neal 14. A Lady with a Headache in the Second Trimester  71 M. Angela O’Neal 15. Ringing in the Ears and Pain in the Head  75 M. Angela O’Neal 16. A Pregnant Woman with Aphasia and Right-​Sided Weakness  79 M. Angela O’Neal 17. Postpartum Visual Disturbance  83 M. Angela O’Neal 18. Postpartum Thunderclap Headache  87 M. Angela O’Neal 19. Postpartum Left-​Sided Numbness and Right-​Sided Shaking  91 M. Angela O’Neal 20. Acute Headache in Pregnancy  95 M. Angela O’Neal 21. The Worst Headache of Her Life  99 M. Angela O’Neal 22. A Woman in Labor with Hypotension and Dyspnea after Epidural Placement  103 Janet Waters 23. Weakness in the Hand of a Woman During Pregnancy  109 Janet Waters 24. A Woman with Leg Weakness After Delivery  113 Janet Waters 25. A Young Woman with Double Vision and Fatigue  119 Janet Waters 26. Multiple Sclerosis  125 Tamara B. Kaplan and Marcelo Matiello 27. A Mother Who Could Not See Her Baby  133 Marcelo Matiello and Tamara B. Kaplan

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Contents

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28. “I Am Pregnant; Why Can’t I Sleep?”  139 Sandra L. Horowitz 29. Convulsion in a Pregnant Woman  143 Eudocia Q. Lee

SECTION 3. WOMEN’S HEALTH AND AGIN G 

30. Cognitive Concerns  151 M. Angela O’Neal 31. “Will I Have a Stroke?”  155 M. Angela O’Neal 32. Involuntary Movements  159 Chizoba Umeh 33. Memory Concerns in Middle Age  163 Marie Pasinski 34. Pain in the Back  169 M. Angela O’Neal Index  173

Contents

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Preface I wanted to write a book that addressed the common problems clinicians face in caring for women with neurological disorders. The gender-​specific neurological issues clearly vary at different points in a woman’s life. For example, these issues might include questions about reproductive health, pregnancy, or healthy aging. The book’s raison d’être is to heighten caregivers’ awareness about the gender differences in neurological care. A range of topics about women’s health and neurological disorders is discussed, including: headache, stroke, epilepsy, neuropathy, Parkinson’s disease, and Alzheimer’s disease. The case scenarios are illustrative of common dilemmas we all face in caring for female patients. The discussions weigh the evidence available to help us make informed decisions with the best information on the particular topic. The cases are meant to demonstrate a best-​ practice clinical algorithm. Topics covered in the book include issues that are unique to women, as well as those that may affect both men and women, but may have a different risk, prevalence, presentation, or treatment considerations for women. The book’s format is based on the “What Do I Do Now?” texts, using case examples of common problems and questions that involve women with neurological disease and discussing how to best address the key issues. The aim is to give practical advice for everyday problems clinicians face in caring for women. There is a lack of knowledge about how sex and gender may affect neurological illnesses. In addition, much of the research in this area is emerging or not widely publicized. Therefore, it can be challenging for physicians to stay on top of the latest research about how sex and gender affect the course of specific diseases, medication effects, and best neurological care. The book is meant to be a “go-​to” manual to delineate best practices in women’s neurology. It is written in a succinct straightforward style with tables, figures, and references illustrating the key clinical points. This book is unique as it addresses neurological problems women face throughout their lives, whereas previous texts in this area have been limited to neurological disorders that occur in pregnancy. The case-​oriented format addressing the common clinical scenarios makes the book practical, relevant, and easy to read.

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I hope you will enjoy reading the cases and working through the decision analyses. The authors did a great job in clarifying the dilemmas we all face on a regular basis in patient care. I know your female patients will benefit from the additional knowledge and expertise you gain after reading Women’s Neurology. —​Angela O’Neal, MD

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Preface

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Contributors

Regina Krel, MD Angels Neurological Centers, PC Brighton, Massachusetts Paul G. Mathew, MD, FAAN, FAHS John R. Graham Headache Center Department of Neurology Brigham and Women’s Hospital Harvard Vanguard Medical Associates Cambridge Health Alliance Harvard Medical School Boston, Massachusetts Tamara B. Kaplan, MD Partners Multiple Sclerosis Center Department of Neurology Brigham and Women’s Hospital Boston, Massachusetts Marcelo Matiello, MD, MSc Department of Neurology Massachusetts General Hospital Harvard Medical School Boston, Massachusetts Chizoba Umeh, MD Department of Neurology Brigham and Women’s Hospital Boston, Massachusetts Eudocia Q. Lee, MD, MPH Center for Neuro-​Oncology Dana Farber Cancer Institute Brigham and Women’s Hospital Boston, Massachusetts

Alexandra Lovett, MD Department of Neurology Massachusetts General Hospital Brigham and Women’s Hospital Boston, Massachusetts Whitney Woodmansee, MD Department of Endocrinology Brigham and Women’s Hospital Boston, Massachusetts P. Emanuela Voinescu, MD, PhD Department of Neurology Epilepsy Division Brigham and Women’s Hospital Boston, Massachusetts Janet Waters, MD, MBA Women’s Neurology Magee Women’s Hospital University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Marie Pasinski, MD Department of Neurology Harvard Medical School Charlestown HealthCare Center Massachusetts General Hospital Charlestown, Massachusetts

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Sandra L. Horowitz, MD Department of Neurology Brigham and Women’s Hospital Boston, Massachusetts Na Tosha N. Gatson, MD, PhD Department of Neurology Geisinger Health System Danville, Pennsylvania

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Contributors

Terri L. Woodard, MD Department of Gynecologic Oncology Reproductive Medicine University of Texas MD Anderson Cancer Center Houston, Texas

SECTION 1

Issues in Women During Their Reproductive Years

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1

Hormonal Contraception in a Woman with Headache M. Angela O’Neal

A 27-​year-​old woman comes for evaluation of long-​ standing headaches. She reports the headaches began in high school, and are usually right hemicranial and throbbing in nature. They are often preceded by shimmering zigzag lines, which occur out of the right side of her vision. These visual phenomena are often followed by a right visual field loss. The visual symptoms typically last about 20–​30 minutes. The headaches are associated with light sensitivity as well as nausea and vomiting. They occur at least once a week and last 24–​4 8 hours. She has previously tried amitriptyline, propranolol, and Excedrin migraine tablets without success. She has not noticed any clear triggers for her headaches. Her past medical history is unremarkable. Her current medications are Ortho-​Tri-​Cyclen and naproxen PRN (i.e., as needed). She drinks alcohol occasionally and smokes cigarettes, about one pack a day. Her examination is normal.

What do you do now? 3

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MIGRAINE AND HORMONAL CONTRACEPTION

Diagnosis

This lady suffers from migraine with aura. The diagnosis of migraine with aura can be confidently made on a clinical history based on the International Headache Society (IHS) criteria for migraine with aura shown in Box 1.1. Patients with a new presentation of probable migraine with aura need imaging, usually a brain magnetic resonance image (MRI) and neck and brain vascular imaging to exclude secondary headaches that can mimic migraine. Migraine has been reported to affect as many as 43% of women in the United States. The prevalence of migraine increases with age such that in the 35–​39-​ year age bracket, as many as 37% of women may be affected. The prevalence of migraine with aura is 4.4%.1 Combined hormonal contraception (CHC) is the most commonly prescribed method of contraception. A US Health and Human Services survey from 2006–​2008 found that 10.4  million women ages 15–​44 used an oral contraceptive pill (OCP).2 Therefore, choosing the appropriate candidate for this method is important. There are several significant issues in choosing an appropriate contraceptive method in women who have migraine with aura. These concerns include: the risk of stroke with CHCs, the risk of stroke in migraineurs with aura, and choosing the appropriate contraception method for a

BOX 1.1 

IHS Diagnostic Criteria for Migraine with Aura

Must fulfill criteria for migraine listed above, and in addition, at least two attacks fulfilling the following criteria. Aura consisting of at least one of the following, but no motor weakness: 1. Fully reversible visual symptoms, including positive features (flickering lights, spots, or lines) and/​or negative features (i.e., loss of vision) 2. Fully reversible sensory symptoms, including positive features and/​or negative features 3. Fully reversible dysphasic speech disturbance At least two of the following other characteristics: 1. Homonymous visual symptoms and/​or unilateral sensory symptoms 2. At least one aura symptom develops gradually over ≥ 5 min, and/​ or different aura symptoms occur in succession over ≥ 5 min 3. Each symptom lasts ≥ 5 and 200 mg/​d

Valproate

No effect

Calcium channel blocker

Verapamil

No effect

Tricyclic antidepressants

Amitriptyline

No effect

WHAT DO I DO NOW? Section 1 Issues in Women During Their Reproductive Years

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method. However, a discussion about why an effective contraceptive method is needed is important, as topiramate is a pregnancy class D medication. 4. Abortive therapy with a triptan would also be appropriate. 5. She should initiate a headache diary to follow her migraine frequency and identify triggers, which would be discussed at her follow-​up evaluation.

KEY POINTS TO REMEMBER

1. There is a small risk of stroke related to OCPs that is attributed to estrogen. 2. The risk of stroke related to CHCs increases with age and other traditional stroke risk factors; so, for women over the age of 45, especially with other stroke risk factors, another form of contraception should be considered. 3. Migraine with aura increases the risk of IS by 2.5 times, but the absolute number of strokes is small. 4. For women who have migraine with aura, CHCs should be avoided.

References 1. Stewart WF, Wood C, Reed ML, et al. Cumulative lifetime migraine incidence in women and men. Cephalalgia. 2008;28:1170–​1178. 2. Mosher, WD. Use of contraception in the United States: 1982–​2008. Vital Health Stat. 2010;23(29):1–​44. 3. Gillum LA, BA, Mamidipudi SK, Johnston SC. Ischemic stroke risk with oral contraceptives: a meta-​analysis. JAMA. 2000;284(1):72–​78. 4. Lidegaard O, Løkkegaard E, Jensen A, et al. Thrombotic stroke and myocardial infarction with hormonal contraception. NEJM. 2012;366:2257–​2266. 5. Spector JT, Kahn SR, Jones MR, et al. Migraine headache and ischemic stroke risk: an updated meta-​analysis. Am J Med. 2010;123(7):612–​624. 6. Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women. Stroke. 2014;45(5):1545–​1588.

1.  Hormonal Contraception in a Woman with Headache

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2

A Young Woman with Jerking Movements M. Angela O’Neal

A 20-​year-​old lady presents for evaluation of seizures. She has had episodic jerking movements over the past year, which have increased over the last several months. She has fallen twice when the jerks involved her legs. They seem to be correlated with times when she gets poor sleep. She was recently seen in the emergency department (ED) after blacking out. She had stayed up late studying for a final. She woke to go to the bathroom, experienced several of these jerks, and then blacked out. Her roommate found her on the floor and called an ambulance. She denied any tongue bite or incontinence, but did admit to being generally sore and “foggy” when she woke up. The ED physician ordered a brain MRI, which was normal, and an electroencephalogram (EEG). She has anxiety and depression. Medications: fluoxetine 20 mg daily and a combined hormonal contraceptive.

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On exam, height is 66 inches and weight is 200 lbs. Her neurological exam is normal. A sample portion of her EEG is shown in Figure 2.1.

What do you do now?

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FIGURE 2.1   AP Bipolar montage showing typical high-​voltage generalized 3–​4 Hz spike polyspike wave

characteristic for JME.

ANTICONVULSANTS AND HORMONAL CONTRACEPTION

This woman has juvenile myoclonic epilepsy (JME). This is one of the most common forms of generalized epilepsy, accounting for up to 25–​30% of all idiopathic generalized epilepsy.1 It is characterized by the triad of myoclonic jerks, generalized tonic clonic epilepsy, and absence seizures. Seizures typically occur in the morning and, as with this patient, are often triggered by sleep deprivation. In JME, the myoclonic jerks are epileptic. In general, JME is usually well controlled with medication, but most patients require lifelong anticonvulsant therapy. Treatment for JME is with antiepileptic drugs (AEDs), which are effective for primary generalized epilepsy. In choosing an AED for a young woman of reproductive age, there are multiple considerations besides the efficacy of the medication. Some of these considerations include: the effect of an AED on her other medical conditions, potential medication interactions, long-​term side effects, and teratogenic risk during pregnancy. In the context of our patient, there are several potentially efficacious medications. Let’s weigh the choices. Valproate is the best-​studied and recommended first-​line medication to treat JME. In one study for idiopathic generalized epilepsy, remission was seen in 52% of patients treated with valproate monotherapy, 17% for lamotrigine, and 34.6% for topiramate. Other studies have demonstrated that levetiracetam may be as

2.  A Young Woman with Jerking Movements

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BOX 2.1 

AEDs Used for Primary Generalized Epilepsy and Degree

of Induction of Metabolism of Hormonal Contraceptives WEAK INDUCERS

Topiramate Lamotrigine NON-​I NDUCERS

Levetiracetam Valproate Zonisamide

effective as valproate in treating JME. Zonisemide may also be an effective AED in treating generalized epilepsy, but this is less well documented.2 Box 2.1 shows the potential interactions with each AED used for primary generalized epilepsy and combined hormonal contraceptives (CHCs). Side effects to be considered for our patient include weight gain and exacerbation of her mood disorder. Valproate would not worsen her mood disorder, but weight gain, hair loss, and polycystic ovarian syndrome are known side effects. Lamotrigine, levetiracetam, and zonisamide are weight-​neutral, whereas topiramate often causes weight loss. Levetiracetam can worsen anxiety, and topiramate in doses used to treat epilepsy may cause cognitive slowing. There are considerable data documenting the teratogenic side effects of valproate, as well as long-​term effects on fetal cognitive development. Therefore, despite its efficacy, it may not be the first choice of medication for women of reproductive age with JME. Topiramate is also a known teratogen. After a discussion with the patient, it was agreed to initiate levetiracetam.3 Table 2.1 shows each AEDs’ pregnancy classification. Levetiracetam was initiated, which controlled her JME. However, her anxiety worsened, so lamotrigine was gradually up-​titrated and levetiracetam withdrawn. Folate supplementation was begun at the time of the AED initiation. WWE have about twice the risk of neural tube defects, NTDs. Maternal folate deficiency has been linked with the development of NTDs, and periconceptional folate supplementation with a reduction of risk. It is not clear whether folate supplementation has a comparable protective effect for WWE. The American Academy of Neurology recommends the administration of 1–​4 mg of folate for all WWE of child bearing potential.4

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WHAT DO I DO NOW? Section 1 Issues in Women During Their Reproductive Years

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TABLE 2.1  

AEDs Used for Primary Generalized

Epilepsy Pregnancy Classification AED

Pregnancy Classification

Valproate

D

Topiramate

D

Lamotrigine

C

Levetiracetam

C

Zonisamide

C (fewer data available)

She was educated about the role of sleep deprivation as an epilepsy trigger, instructed as to safety concerns, and told not to drive for six months.

KEY POINTS TO REMEMBER

1. Valproate is the most effective AED for JME. 2. Due to concerns about valproate teratogenicity in a woman of reproductive age, other options should be considered. 3. The effect of an AED on metabolism of CHC needs to be considered and discussed. 4. Women with epilepsy in the childbearing years on an AED should also be taking folate supplementation.

References 1. Hauser WA. The prevalence and incidence of convulsive disorders in children. Epilepsia. 1994;35(Suppl 2):S1–​S6. 2. Nicolson A, Appleton RE, Chadwick DW, Smith DF. The relationship between treatment with valproate, lamotrigine, and topiramate and the prognosis of the idiopathic generalized epilepsies. J Neurol Neurosurg Psychiatry. 2004; Jan;75(1):75–​79. 3. Harden CL, Meador KJ, Pennell P, et al. Practice parameter update: management issues for women with epilepsy—​focus on pregnancy (an evidence-​based review): teratogenesis and perinatal outcomes: report of the Quality Standards Subcommittee and Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and American Epilepsy Society. Neurology. 2009 Jul 14;73(2):133–​141. 4. Morrell MJ. Folic Acid and Epilepsy. Epilepsy Curr. 2002 Mar;2(2):31–​34.

2.  A Young Woman with Jerking Movements

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3 Headache Regina Krel and Paul G. Mathew

A 26-​year-​old female presents with throbbing unilateral headaches with an 8/​10 intensity. They are associated with photophobia, phonophobia, nausea, and vomiting. She denies visual, sensory, language, or motor disturbances suggesting aura. Individual attacks last 6–​24 hours, and she estimates having seven headache days per month that tend to have a strong menstrual association. The majority of headaches begin two days prior to the onset of her menstrual cycle, and continue three days into menstruation. Her menstrual cycles are regular, occurring at 28-​day intervals. She has no other medical problems, and is not taking any medications. She has no allergies, and denies any tobacco or illicit drug use. There is a family history of migraines involving her mother and maternal grandmother. Her neurological examination was unremarkable.

What do you do now?

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MENSTRUALLY RELATED MIGRAINE

At first glance, her diagnosis is seemingly obvious: migraine. The description of her headache fulfills criteria for episodic migraine without aura.1 Migraines that have a menstrual association are further classified as pure menstrual migraine without aura, or menstrually related migraine without aura (Box 3.1). In this case, the patient has menstrually related migraine without aura, as this patient experiences some migraines outside of her menstrual periods. The prevalence of menstrually related migraine can range from 20–​60%, while pure menstrual migraine occurs in less than 10% of women.8 Menstrual migraine attacks are typically not associated with aura symptoms. They tend to be more severe, longer lasting, more resistant to treatment, and associated with higher rates of functional disability.2 A diary documenting migraines and menstrual cycles should be kept over the course of three consecutive cycles. A diagnosis of menstrually related migraine can be confirmed when two of those menstrual cycles correlate with migraine onset within –​2 to +3 days of menses. In contrast to sufferers of pure menstrual migraine, menstrually related migraine patients also have attacks at other points in their cycle. Studies evaluating the relationship between the onset of migraine attack and its correlation to menstruation demonstrated a strong association with the natural

BOX 3.1 

Diagnostic Criteria for Menstrual Migraine

PURE MENSTRUAL MIGRAINE WITHOUT AURA

Diagnostic criteria: A. Attacks, in a menstruating woman, fulfilling criteria for Migraine without aura and criterion B below B. Documented and prospectively recorded evidence over at least three consecutive cycles has confirmed that attacks occur exclusively on day 1 +/​–​2 (i.e., days –​2 to +3) of menstruation in at least two out of three menstrual cycles and at no other times of the cycle. MENSTRUALLY RELATED MIGRAINE WITHOUT AURA

Diagnostic criteria: A. Attacks, in a menstruating woman, fulfilling criteria for Migraine without aura and criterion B below B. Documented and prospectively recorded evidence over at least three consecutive cycles has confirmed that attacks occur on day 1+/​–​2 (i.e., days –​2 to +3) of menstruation in at least two out of three menstrual cycles, and additionally at other times of the cycle.

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WHAT DO I DO NOW? Section 1 Issues in Women During Their Reproductive Years

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drop in estrogen during the late luteal phase of the menstrual cycle. For women who have regular cycles and in whom a diagnosis of menstrually related migraine has been made, spot prophylactic or perimenstrual prophylactic treatment may be indicated. Prophylactic options can include nonsteroidal anti-​inflammatory drugs (NSAIDs), triptans, and hormonal options.5,6,7 Medication dosage options include:8 • Naproxen sodium 550 mg twice daily for 5–​14 days, starting the week before anticipated period onset. • Frovatriptan to be started two days before period onset, with 5 mg taken twice daily on day 1, then 2.5 mg twice daily for six days. • Naratriptan 1 mg twice daily for six days to be started three days before period onset. • Zolmitriptan 2.5 mg twice or three times daily for seven days starting two days before expected period onset. Hormonal options, such as estrogen supplementation, are geared to maintaining steady levels of estrogen, thus forestalling the abrupt drop that occurs during the late luteal phase. Since estrogen-​based contraceptives are associated with an increased risk of stroke, and patients who suffer from migraine with aura carry a slightly increased risk of stroke, physicians should consider the use of progesterone-​only formulations.

KEY POINTS TO REMEMBER

• Menstrually related migraines tend to be longer lasting, more debilitating, and more resistant to standard acute treatments than non-​menstrual migraines. • The diagnosis of menstrual migraine is made based on history, physical examination, and analysis of headache diaries demonstrating a menstrual relationship to headache in two out of three menstrual cycles. This diagnosis should be made after secondary headaches have been ruled out. • Pathophysiology of menstrual migraine is thought to be related to the abrupt drop in estrogen in the late luteal phase and an increase in prostaglandins. • Perimenstrual prophylaxis with NSAIDs, triptans, or hormones may be beneficial in reducing frequency and intensity of menstrually related migraine attacks.

3. Headache

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References 1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629–​808. doi:10.1177/​0333102413485658 2. Mathew PG, Dun EC, Luo JJ. A cyclic pain. Obstet Gynecol Surv. 2013;68(2):130–​140. doi:10.1097/​ogx.0b013e31827f2496 3. MacGregor EA, Victor TW, Hu X, et al. Characteristics of menstrual vs nonmenstrual migraine: a post hoc, within-​woman analysis of the usual-​care phase of a nonrandomized menstrual migraine clinical trial. Headache. 2010;50(4):528–​538. doi:10.1111/​j.1526-​4610.2010.01625.x 4. Vetvik KG, Benth JS, Macgregor EA, Lundqvist C, Russell MB. Menstrual versus non-​ menstrual attacks of migraine without aura in women with and without menstrual migraine. Cephalalgia. 2015;35(14):1261–​1268. doi:10.1177/​0333102415575723 5. Macgregor EA, Frith A, Ellis J, Aspinall L, Hackshaw A. Prevention of menstrual attacks of migraine: a double-​blind placebo-​controlled crossover study. Neurology. 2006;67(12):2159–​2163. doi:10.1212/​01.wnl.0000249114.52802.55 6. Brandes J, Poole A, Kallela M, et al. Short-​term frovatriptan for the prevention of difficult-​to-​treat menstrual migraine attacks. Cephalalgia. 2009;29(11):1133–​1148. doi:10.1111/​j.1468-​2982.2009.01840.x 7. Macgregor EA. Contraception and headache. Headache. 2013;53(2):247–​276. doi:10.1111/​head.12035 8. Macgregor EA. Migraine management during menstruation and menopause. Continuum. 2015;21:990–​1003. doi:10.1212/​con.0000000000000196

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WHAT DO I DO NOW? Section 1 Issues in Women During Their Reproductive Years

4 Seeing Spots Regina Krel and Paul G. Mathew

A 37-​year-​old female presents to the emergency department complaining of right arm numbness and tingling as well as seeing flashing spots and lines, which have persisted for two hours. She was in her usual state of health until two hours ago, when she noticed these symptoms. She has a history of migraine with visual aura, but her visual symptoms typically last less than 10 minutes, and are usually followed by a unilateral headache. She recalls one visual aura that was followed by right arm numbness and tingling, but this sensory disturbance only lasted a few minutes. In the emergency department, she endorses a throbbing, right-​sided headache, which is associated with photophobia, phonophobia, and nausea. At the onset of this episode, she took sumatriptan, which is usually effective, but it did not seem to improve her symptoms. She denies any weakness, numbness/​ tingling on the left side, difficulty speaking, or difficulty understanding spoken language. Her past medical history is otherwise unremarkable. She has a family history

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of migraine. She denies tobacco, alcohol, or recreational drug use. On examination, vital signs are within normal limits. The patient has intact sensation with preserved strength. Extraocular movements were intact, but a dense visual field cut is noted on the right side. The rest of her neurological exam is unremarkable. A non-​contrast head CT was negative for acute pathology, however a brain MRI revealed an acute left occipital infarct (Figure 4.1).

What do you do now?

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FIGURE 4.1   Diffusion weighted MRI Brain image demonstrating an acute left occipital infarct.

MIGRAINE AND STROKE

It can be easy to dismiss this case as a typical migraine with aura in a young female patient with a prior history of similar episodes, but the persistence of aura beyond 60 minutes should prompt further neurological evaluation. The brain MRI in this patient confirmed an acute stroke, and her diagnosis is highly suspicious for a migrainous infarction. A migraine-​induced stroke or migrainous infarction has specific criteria, which have been set by the International Classification of Headache Disorders, Third Beta Edition (ICHD). The patient should have a prior history of migraine with aura, and should have a typical aura lasting longer than 60 minutes, with neuroimaging confirming a stroke in the corresponding region of the brain. The stroke cannot be attributed to any other causal mechanism (Box 4.1).7 When evaluating a stroke in a young adult, in addition to MR imaging, the following should be performed9: head and neck angiography, electrocardiogram, hypercoagulability studies, transesophageal echocardiogram, urine toxicology screen, fasting lipid profile, markers of inflammation (i.e., erythrocyte sedimentation rate/​c-​reactive protein [ESR/​CRP]), basic metabolic panel, and complete blood count. The patient should also be placed on continuous telemetry. Studies demonstrate a nearly two-​fold increased risk of stroke in patients with migraine. In addition, this risk is higher in younger adults, particularly women under 45 years old, and in those with increased frequency of migraine with aura attacks. The combination of smoking and oral contraceptive use among

4.  Seeing Spots

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2

BOX 4.1 

Migrainous Infarction

Description: One or more migraine aura symptoms associated with an ischemic brain lesion in the appropriate territory, demonstrated by neuroimaging. Diagnostic criteria: A. A migraine attack fulfilling criteria B and C B. Occurring in a patient with Migraine with aura and typical of previous attacks, except that one or more aura symptoms persists for >60 minutes C. Neuroimaging demonstrates ischemic infarction in a relevant area D. Not better accounted for by another diagnosis.

young females with migraine aura has been shown to increase stroke risk by a factor of approximately 9 when compared with women without migraine.3 The World Health Organization designates combined hormonal contraceptive use in patients who suffer from migraine with aura as category 4 in terms of medical eligibility criteria. This category states that the condition poses an unacceptable health risk, and that alternative contraceptives should be considered.8 Despite these risk factors, migrainous infarction is very infrequent, according to the Lausanne Stroke Registry and the Dijon Stroke Registry, which demonstrated migraine-​induced strokes occurring in 0.3% and 0.5% of cases, respectively.4,5 The pathophysiology leading to migrainous infarction or to an increased risk of stroke remains unclear, although several theories have been speculated. These include cortical spreading depression (CSD) leading to stroke, increased rate of patent foramen ovale (PFO) in patients with migraine, and the questionable increased risk of cervical artery dissection. CSD is thought to usually originate in the occipital lobe and to be responsible for migraine aura. CSD is characterized by a wave of neuronal depolarization followed by suppression crossing vascular territories, with related changes in blood flow moving across the cerebral cortex at a rate of 3 mm/​min. Some of the changes in blood flow include both hyperemia and transient oligemia, which may lead to migrainous infarction.2 The association between migraine and PFO has been demonstrated in a case controlled study performed by Anzola et al. The authors concluded that 48% of patients who suffered from migraine with aura were also found to have a PFO, compared to 23% of patients who have migraine without aura, and 20% in a control group. Given the increased risk of stroke in patients who have migraine

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with aura and the association of PFO in these migraineurs, the mechanism could potentially be explained by paradoxical emboli.2 Regarding cervical artery dissection, a recent meta-​analysis concluded that migraine nearly doubled the risk of dissection. The risk was noted to be slightly higher in patients who suffer from migraine with aura, but this was not found to be statistically significant. The etiology of this increased risk still remains uncertain.3 Despite evidence suggesting that there is an increased risk of stroke in patients with migraine with aura, the absolute risk of stroke still remains relatively low. KEY POINTS TO REMEMBER

• Migrainous infarction should be considered in any patient who has a persistent aura lasting longer than 60 minutes. • There is a two-​fold increased risk of stroke in patients with migraine. This is particularly true for women under the age of 45 who suffer from migraine with aura. • Theories potentially explaining the increase risk of stroke include vascular changes associated with cortical spreading depression, higher rates of patent foramen ovale, and the association with cervical artery dissection.

References 1. Bousser M, Welch KM. Relation between migraine and stroke. Lancet Neurol. 2005;4(9):533–​542. doi:10.1016/​s1474-​4422(05)70164-​2 2. Katsarava Z, Weimar C. Migraine and stroke. J Neurol Sci. 2010;299(1–​2):42–​44. doi:10.1016/​j.jns.2010.08.058 3. Kurth T, Diener H. Migraine and stroke: perspectives for stroke physicians. Stroke. 2012;43(12):3421–​3426. doi:10.1161/​strokeaha.112.656603 4. Milhaud D, Bogousslavsky J, Melle GV, Liot P. Ischemic stroke and active migraine. Neurology. 2001;57(10):1805–​1811. doi:10.1212/​wnl.57.10.1805 5. Sochurkova D, Moreau T, Lemesle M, Menassa M, Giroud M, Dumas R. Migraine history and migraine-​induced stroke in the Dijon Stroke Registry. Neuroepidemiology. 1999;18(2):85–​91. doi:10.1159/​0 00069411 6. Spector JT, Kahn SR, Jones MR, Jayakumar M, Dalal D, Nazarian S. Migraine headache and ischemic stroke risk: an updated meta-​analysis. Am J Med. 2010;123(7):612–​624. doi:10.1016/​j.amjmed.2009.12.021 7. The International Classification of Headache Disorders, 3rd ed. (beta version). Cephalalgia. 2013;33(9):629–​808. doi:10.1177/​0333102413485658 8. World Health Organization. 2015. Medical Eligibility Criteria for Contraceptive Use. 5th ed. Geneva: World Health Organization, p. 126. 9. Mackey J. Evaluation and management of stroke in young adults. Continuum. 2014;20, 352–​369. doi:10.1212/​01.con.0000446106.74796.e9

4.  Seeing Spots

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Seizures Occurring Once a Month M. Angela O’Neal

A 36-​year-​old woman is referred for evaluation for epilepsy, which had started one year previously. Her boyfriend, who had witnessed many of the seizures, described them as beginning with a yawn, followed by a high-​pitched scream. The patient then would lose tone. This was followed by a tonic posture with arms flexed and legs extended. Occasionally she would then have brief clonic movements. The seizures were usually 1–​2 minutes in duration and followed by a postictal confusion lasting up to 15 minutes. She usually has one seizure a month, typically at the onset of her menses. Her menses are regular. She is currently on levetiracetam 500 mg in the morning and 750 mg at night. Brain MRI was normal. Her electroencephalogram was also normal. Her exam is normal.

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CATAMENIAL EPILEPSY

Hormones can alter seizure frequency, through modulation of brain excitability as well as through their effect on anticonvulsant drug concentrations. Animal studies have suggested that estrogen is a proconvulsant. Whereas progesterone, particularly its metabolite allopregnanolone, promotes neuroinhibition and acts as an anticonvulsant.1 Catamenial epilepsy is defined when seizure frequency increases correlated with certain phases of the menstrual cycle. A  catamenial pattern may be seen with any type of epilepsy, but it is more common with focal epilepsies. Using the definition that there is a doubling of seizure frequency associated with a particular phase of the menstrual cycle, up to one-​third of women have catamenial epilepsy. A normal menstrual cycle is 28 days, with day 1 defined as the first day of menses, and day 14, the day of ovulation. The first half of the menstrual cycle, days 1–​14, is called the follicular phase, and the second half, days -​14 to -​1, the luteal phase. Different patterns of catamenial epilepsy have been described. The most common type, as demonstrated by this patient, is the perimenstrual exacerbation, (C1). This corresponds to a progesterone decline. The next most common pattern is the periovulatory exacerbation, (C2). This is characterized by an increase in seizure frequency associated with ovulation and the associated surge in estrogen. The luteal pattern, (C3), is the least frequent. In this pattern, seizure frequency increases in the luteal phase of the menstrual cycle. This is associated with relatively low progesterone levels and anovulatory cycles.2 Most treatments have focused on the C1 pattern. Acetozolamide at doses of 250–​500 mg daily, three to seven days before menses, has been shown to be efficacious. Benzodiazepines have also been used especially for seizure clusters. The only benzodiazepine proven to have efficacy is clobazem. In a randomized controlled trial, clobazem was shown to be more effective than placebo. A trial with cyclic progesterone lozenges was ineffective in women with intractable partial seizures. However, there was a benefit for the subgroup of women with the C1 pattern who had greater than three times exacerbation of their seizures. The final strategy would be to increase the anticonvulsant dose during the phase of the catamenial exacerbation.3

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KEY POINTS TO REMEMBER

1. Many women have a catamenial exacerbation of their epilepsy. 2. Defining the specific catamenial pattern is an important step in deciding on treatment strategy. 3. Acetozolamide, clobazem, and cyclic progesterone lozenges, for the C1 pattern only, are effective in suppressing the catamenial seizure exacerbation. An alternative approach would be to increase the antiepileptic drug dose during the time of exacerbation.

References 1. Harden CL, Pennell PB. Neuroendocrine considerations in the treatment of men and women with epilepsy. Lancet Neurol. 2013;12(1):72–​83. 2. Herzog AG, Klein P, Ransil BJ. Three patterns of catamenial epilepsy. Epilepsia. 1997;38:1082–​1088. 3. Pennell PB. Pregnancy, epilepsy, and women’s issues. Continuum. 2013;19(3):697–​714.

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Multiple Ovarian Cysts in a Woman with Epilepsy M. Angela O’Neal

A 24-​year-​old woman with idiopathic partial with secondary generalized epilepsy presents to your clinic. Her seizures began at age 12. She experiences no aura; witnesses have reported her seizures to be generalized tonic followed by clonic movements with associated incontinence. She experiences postictal confusion lasting around 30 minutes. Prior brain MRI was normal and previous EEGs have demonstrated a left temporal epileptiform focus. Since age 15, she has been on valproate, with no seizures for two years. She has gained 30 pounds over the last several years. Her past medical history is remarkable for irregular periods for which she was recently evaluated by an obstetrician gynecologist. Her labs showed an elevated testosterone level, and abdominal ultrasound showed multiple ovarian cysts. A diagnosis of polycystic ovarian syndrome (PCOS) was made.

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Her medications are a Mirena IUD and Depakote ER 750 mg bid. She is 64 inches tall and weighs 225 lbs. Her weight is predominantly central, and she has alopecia in a male pattern. Her neurological exam is normal.

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ANTIEPILEPTIC DRUGS AND POLYCYSTIC OVARIAN SYNDROME

Epilepsy as a Cause of Reproductive Dysfunction

There are numerous reports that epilepsy, particularly focal epilepsy, can cause hypothalamic dysfunction. However, many of these studies are confounded by being retrospective, using subjects who presented to tertiary epilepsy centers and are on treatment with AEDs. There are multiple connections between the limbic cortex and hypothalamus that modulate the hypothalamus–​pituitary hormonal secretion. For example, it is well known that, following a generalized seizure, there can be elevated prolactin levels. The gonadotropin-​releasing hormone (GnRH) is vulnerable to injury following seizures. Dysfunction of GnRH may lead to abnormal release of follicle-​stimulating hormone (FSH) and luteinizing hormone (LH), with direct effects on ovulation and the maturation of ovarian follicles. In addition, there has been some suggestion from small studies that a left temporal focus may be more associated with PCOS.1 Polycystic Ovarian Syndrome

PCOS is a diagnosis made on ultrasound and per anatomical criteria, with these showing the presence of multiple ovarian cysts. This is distinct from PCOS where there is endocrine dysfunction. The National Institute of Health consensus definition of PCOS includes the presence of menstrual dysfunction, clinical evidence of hyperandrogenism, and exclusion of other endocrinopathies, such as Cushing’s syndrome and hypothyroidism. The etiology of PCOS is felt to be heterogenous, related to a complex interaction between both genetic and environmental factors. PCOS develops when the ovaries are stimulated to produce excessive testosterone. There are several ways this can occur. First, in women who have PCOS, there is to an abnormal pulse frequency and amplitude of LH. The increased levels of LH drive the ovarian thecal cells to produce more androgen. Many women with PCOS have insulin resistance and are obese. This leads to an increased frequency of GnRH pulses and an increase of LH/​FSH, causing increased androgen production. Anti-​Epilepsy Drugs and Polycystic Ovarian Syndrome

Valproate is the AED most associated with PCOS. Valproate can directly increase ovarian testosterone production. It can also cause weight gain leading to insulin resistance, another mechanism contributing to PCOS. One study looked at switching women with PCOS from valproate to lamotrigine. In the subsequent year, the women had significant weight loss, decreased androgen levels, and a decrease in the number of ovarian follicles.2,3

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In our patient, she has had a significant weight gain of 30 lbs., which is probably related to valproate and is contributing to the metabolic syndrome of PCOS. There should be consideration of switching her to another AED, especially as there are additional teratogenic concerns in a woman of childbearing age. Levetiracetam would be a good choice as an AED for this woman.

KEY POINTS TO REMEMBER

1. Epilepsy may contribute to reproductive dysfunction. 2. Women with epilepsy, especially if treated with valproate, are at high risk to develop PCOS. 3. PCOS is a complex disorder with both genetic and environmental contributors. It develops in women where the ovaries are stimulated to produce excessive testosterone.

References 1. Harden C, Pennell P. Neuroendocrine considerations in the treatment of men and women with epilepsy. Lancet Neurol. 2013;12:72–​83. 2. Bilo L, Meo R. Polycystic ovary syndrome in women using valproate: a review. Gynecol Endocrinol. 2008;24(10):562–​570. 3. Duncan S. Polycystic ovarian syndrome in women with epilepsy: a review. Epilepsia. 2001;42(suppl 3):60–​65.

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Newlywed with Headache, Morning Sickness, and Subjective Right-​side Weakness Na Tosha N. Gatson and Terri L. Woodard

A 26-​year-​old right-​handed woman presented to her primary care physician with a two-​month history of headaches that are worse upon awakening with increasing episodes of nausea, fatigue, and a sense that she is “not as strong as usual” in her right arm. The patient noted that her symptoms did not initially limit her overall ability to work, but she had noticed a steady progression since onset about two months ago. She had returned from her honeymoon two weeks prior to presentation and had initially attributed her symptoms to “stress” and “poor diet” due to wedding planning. She denied seizures. There had been no changes in vision, speech, mentation, or gait. She underwent a contrasted head CT which was concerning for a left cerebral mass. The patient was sent for brain MRI and

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referred to the neuro-​oncologist for further evaluation and recommendation (Figure 7.1). On examination by neuro-​oncology, her pulse is 108; otherwise vitals are normal, and the patient is visibly anxious. Speech and cognition are normal. She has bilateral papilledema, slight right facial droop, decreased acuity right visual field, decreased strength in right hemi-​ body proximally and distally to 4+/​5 in arm and 5–​/​5 in the leg, reflexes are normal and symmetrical, and sensation is normal to touch, pin, temperature, and vibration. Remainder of examination is otherwise unremarkable. The neuro-​oncologist begins to discuss the most likely diagnosis, and next steps. Overwhelmed, the patient interrupts, “But my husband and I are planning to start a family!”

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(a)

(b)

FIGURE 7.1   Magnetic Resonance Imaging (MRI) of brain, T1 weighted post-​contrast images.

Enhancing lesion of left thalamus on axial (a), and coronal (b) views with noted mass effect on surrounding brain structures. Photo courtesy of Dr. Steven Toms, Neurosurgeon.

INFERTILITY ASSOCIATED WITH CANCER TREATMENT

Thalamic Glioblastoma, Limited Treatment Options, and Family Planning

Delays in time-​to-​diagnosis are usually multifactorial. Often, early signs of a developing brain tumor are vague, intermittent, and less likely to alarm patients to seek immediate medical attention. Social, behavioral, or occupational influences, as shown in this case, further hinder patients from seeking medical advice. In addition to patient-​related delays to diagnosis, primary care providers sometimes defer ordering brain imaging for such isolated symptoms in a previously healthy patient. More commonly, the patient described in this case would first be ruled out for pregnancy, viral infectious etiology, or even physical/​emotional exhaustion. Reports of worsening headache, objective focal weakness, and occupational disability, however, are more ominous, and clinicians are likely to pursue advanced brain imaging. Ultimately, in the above case, the patient was found to have a left-​sided deep brain glioblastoma (GBM). GBM is the most lethal primary brain tumor in adults. Despite decades of research aimed at improving patient outcomes, receiving optimized multimodality treatment (including maximal resection, radiation, and chemotherapy) only offers patients a median overall survival of about 15 months.1,2 GBM is difficult to treat due to various factors related to the tumor’s aggressiveness, paucity of therapies that cross the blood–​brain barrier, and often the tumor’s location, which limits maximal surgical debulking. In the presented case, the patient has a dominant-​side deep brain lesion that presents a major neurosurgical risk for

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bleeding, severe morbidity, and mortality. Gross total resection is unrealistic in this case, and subtotal resection, radiation, and chemotherapy are the available management options. The patient might also choose no treatment with the understanding that the aggressive tumor will continue to grow, causing disability and ultimately, death. Also important to this case is timely initiation of therapy. These tumors are very aggressive, and treatment delays result in tumor progression and possibly hastened loss of neurological function. However, treatment planning should never supersede the education and desires of the patient as it pertains to treatment. Use of systemic chemotherapy and radiation to sensitive brain structures could impact patient fertility and should be discussed upfront in this case. The patient should be informed of her risk of treatment-​related infertility, and offered referral to a fertility specialist for discussion of fertility preservation (FP) options that may be available. Discussion includes: (1) assessment of baseline fertility and options for FP, (2) issues surrounding pregnancy after cancer, (3) other options for achieving future parenthood, and (4) follow-​up throughout her survivorship course as indicated.3,4 Issues of survivorship are relevant to address before as well as during the course of treatment. Survivorship-​centered practices are often designed to anticipate patient and caregiver needs. These include social work and case-​management involvement to address potential medical-​legal concerns (power of attorney for healthcare and advance directives), to direct the patient to financial resources (treatment, travel, insurance), and to educate about palliative care and area hospice support. In summary, delays in diagnosis and initiation of treatment are common hurdles in cancer care. At times, even early diagnosis does not improve our ability to consistently deliver optimal care, due to factors related to tumor location, available therapies, and treatment-​related risks. Clinicians must remain mindful of risks associated with the disease as well as treatment of the disease, as these risks might impact the patient, her caregivers, and her overall quality of life (QOL).

KEY POINTS TO REMEMBER

• Treatment: Maximal surgical debulking of tumors is not always a viable option, and patients should understand risks and benefits of the available treatment modalities, including the decision NOT to treat the tumor. Involvement of palliative care teams may be indicated.

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• Ethics: Discussions that address fertility preservation, family planning, and pregnancy prevention should be completed and documented prior to initiation of any treatment. • Survivorship: This usually involves educational, social, and emotional support of patient, which often extends to the caregivers.

References 1. Gilbert MR, Wang M, Aldape KD, et al. Dose-​dense temozolomide for newly diagnosed glioblastoma: a randomized phase III clinical trial. J Clin Oncol. 2013;31(32):4085–​4091. 2. Stupp R, Mason WP, Van Den Bent MJ, et al. 2005. Radiotherapy plus concomitant and adjuvant temozolomide for glioblastoma. N Engl J Med. 2005;352(10):987–​996. 3. Loren AW, Mangu PB, Beck LN, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013 Jul 1;31(19):2500–​2510. 4. Ethics Committee of the American Society for Reproductive Medicine. Fertility preservation and reproduction in patients facing gonadotoxic therapies: a committee opinion. Fertil Steril. 2013;100(5):1224–​1231.

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8

Routine Long-​Term Epilepsy Follow-​up Na Tosha N. Gatson

A 28-​year-​old right-​handed woman presents to her neurologist for continued management of her epilepsy condition. She denies having any changes in her seizure frequency, duration, or semiology. She reports her last seizure was 10 months ago (generalized tonic-​clonic) due to medication noncompliance and dehydration. The patient is otherwise healthy and without complaints. She has been on her current AED since age nine without any concerns and is tolerating therapy well. During your interview, you obtain a social history, which notes the patient is a graduate student, currently sexually active with a long-​term boyfriend, uses oral contraceptives, drinks three to four alcoholic beverages per month on social occasions, drives regularly, and denies use of illicit drugs or tobacco. Her current medications include a daily vitamin B12 supplement and valproic acid (500 mg by mouth three times

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daily). She reports having recently completed a course of antibiotics for a complicated urinary tract infection earlier in the month. Her examination is normal. A urine pregnancy test completed during clinic visit was positive.

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TERATOGENIC MEDICATION

Unplanned Pregnancy, AED Choice, and Teratogenicity Risk Factors

The case described has several classic concerns that could have been addressed at various time points throughout the physician–​patient relationship. Epilepsy is the third most common chronic neurological disorder worldwide. Unfortunately, all first-​line therapies used to treat seizure are associated with some level of risk to the fetus in utero. The U.S. Food and Drug Administration recently published the “Pregnancy and Lactation Labeling Rule,” which changes the format of prescription drug packaging inserts. Specifically, in the pregnancy subsection, former A, B, C, D, X lettering categories used to designate pregnancy risk were replaced with information including a summary of risks, available data, and clinical considerations. These changes aim to better assist providers with evaluating risks versus benefits for using medications in pregnant or nursing mothers (FDA Pregnancy and Lactation Labeling (Drugs) Final Rule, 2014 [accessed Oct. 19, 2016]. Available from: http://​www.fda.gov/​Drugs/​DevelopmentApprovalProcess/​ DevelopmentResources/​Labeling/​ucm093307.htm). Despite decades of research in the area, few mechanism-​targeted therapeutics to treat seizures are available. Instead, patients with epilepsy are treated symptomatically. For this and other reasons, understanding the biological triggers and susceptibilities for seizures is paramount. Interestingly, there are known bidirectional influences of epileptic events on hormonal activity in the central nervous system (CNS). Outside of the role for sex hormones on reproductive and neuronal tissues—​epileptic events themselves have been demonstrated to modulate hormone levels.1 In the above case, as the patient came of a reproductive age, the clinician might have reconsidered the anti-​epileptic therapy being used, based on frequency of dosing and risk in reproductive-​aged women. With recent advances in the field, the decision to use a medication with a better safety profile, such as levetiracetam, usually dosed twice daily, should be considered. While it is notable that all AEDs have some risk for teratogenicity, after the first trimester of pregnancy, the actual seizure event has been reported to increase fetal morbidity and risk pregnancy maintenance. These risks include fetal trauma related to falls, fetal heart rate deceleration, placental abruption, miscarriage, preterm labor, or premature birth.2 In the United States, between 40% and 60% of pregnancies are either unplanned or unintended. In a recently reported retrospective study of 115 women on teratogenic medications, nearly 70% were not using concurrent medical contraception. For the nearly 30% using contraception, oral contraceptives (OCs) had been the method of choice. Sadly, less than 7% reported receiving

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any counseling for a contraceptive plan.3 In the above case, it would have been appropriate to discuss the potential for drug–​drug interactions in a patient on OCs and AEDs. The patient could have potentially experienced failure of her OC and/​or her AED secondary to a drug–​drug interaction with use of an antibiotic regimen while on therapy. A discussion about future pregnancy planning is appropriate at the first visit and at several points throughout the physician–​patient relationship to cover treatment regimens and potential associated risks. Once a pregnancy has been diagnosed in a patient with epilepsy, it is important to link the patient with the appropriate obstetric providers to best evaluate the fetus over the course of the pregnancy, as well as offer more education to the parents. Considering the patient’s wishes to continue or terminate the pregnancy might also present a need for referral to outside appropriate providers. This case is a challenge because the patient is now known to be pregnant while on AEDs and OCs, and there is a potential for other medication and substance exposure to the fetus based on the clinical history provided. Fetal or pregnancy complications might be multifactorial.4,5

KEY POINTS TO REMEMBER

• Prevention: Consider modification of AED of choice in reproductive-​aged women. • Prevention: Folic acid supplementation prior to pregnancy has been shown to significantly reduce the risk for neural tube defects. • Prevention: Frequently discuss pregnancy planning, pregnancy prevention, and common drug–​drug interactions in all patients on therapy. • Evaluation: Always order a pregnancy test for patients with reasonable risk factors prior to prescribing high-​risk teratogenic therapies. • Ethics and referral: Make referral for fertility and reproductive health assessment and education for patients with high risk pregnancy.

References 1. Velíšková J, Desantis KA. Sex and hormonal influences on seizures and epilepsy. Horm Behav. 2013 Feb;63(2):267–​277. 2. Kaplan PW, Norwitz ER, Ben-​Menachem E, et al. Obstetric risks for women with epilepsy during pregnancy. Epilepsy Behav. 2007 Nov;11(3):283–​291.

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3. Bhakta J, Bainbridge J, Borgelt L. Teratogenic medications and concurrent contraceptive use and women of childbearing ability with epilepsy. Epilepsy Behav. 2015 Nov;52(PtA):212–​217. 4. Borgelt LM, Hart FM, Bainbridge JL. Epilepsy during pregnancy: focus on management strategies. Int J Womens Health. 2016 Sep 19;8:505–​517. eCollection 2016. 5. Bauer J, Isojarvi JI, Herzog AG, et al. Reproductive dysfunction in women with epilepsy: recommendations for evaluation and management. J Neurol Neurosurg Psychiatry. 2002;73:121–​125.

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A Young Woman with Infertility Alexandra Lovett and Whitney W. Woodmansee

A 28-​year-​old female presents with infertility. Menarche developed at age 17, and she was diagnosed with PCOS at age 18. Menses had been irregular and she was started on oral contraceptives. These were continued for 10 years. When pregnancy was desired, oral contraceptives were discontinued. Menses did not resume. On review of systems, she reported a long history of headaches, which were assumed to be migraines. They occurred approximately once per week and were characterized as right-​sided with associated nausea and photophobia. She also reported intermittent galactorrhea with expression over the last three to four years. Her physical examination was normal.

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PROLACTINOMA

Prolactinomas are generally benign and are the most common type of hormone-​ secreting pituitary adenoma. Most prolactinomas are considered microadenomas, which are defined by size less than 1 centimeter (cm).1 Macroadenomas (size ≥1  cm) are more likely to cause symptoms associated with mass effect, including but not limited to headaches, cranial nerve abnormalities, and visual disturbances. Classic visual disturbance would be a bitemporal hemianopia due to compression of the optic chiasm; however, patients may have a unilateral hemianopia or quadrantopia depending on where the visual pathway is affected. Hyperprolactinemia is associated with hypogonadotropic hypogonadism, and women may present with galactorrhea, menstrual irregularities, and infertility; however, many women are asymptomatic. Postmenopausal women and men with prolactinomas tend to present later with larger tumors and accompanying mass effects than premenopausal women, since there is no observable disruption of a menstrual cycle in these individuals. In assessing a woman with infertility, serum prolactin levels should always be checked. In most laboratory assays, a prolactin level of less than 25 micrograms/​ liter (µg/​L) would be considered normal for a nonpregnant woman.1,2 Prolactin levels of greater than 10 times the laboratory upper limit of normal3 or greater than 250 µg/​L are often considered diagnostic of a prolactinoma.4,5 If the prolactin level is elevated, a thorough investigation of potential etiologies should be performed to assess for physiological and medication-​induced causes. A pregnancy test and TSH level should be checked, as both pregnancy and primary hypothyroidism can cause hyperprolactinemia.2–​4 The patient’s medication list should be reviewed for medications that are associated with hyperprolactinemia, with the most common culprits being dopamine antagonist medications, including but not limited to antipsychotics, antihistamines, antidepressants, estrogen agonists, cholinergic agonists, and antiemetics.2–​4 Of note, exercise, sleep, stress, and breastfeeding can cause a physiological hyperprolactinemia.2–4 Chronic renal and hepatic failure can reduce the clearance of prolactin and cause hyperprolactinemia.2–​4 If the patient is not pregnant, and the above factors are excluded, an elevated prolactin level should then prompt an MRI study with a pituitary protocol, which would entail thin coronal sections through the pituitary and the administration of intravenous (IV) gadolinium. The normal pituitary gland is homogenously enhancing and fits nicely into the sella turcica, with a rounded appearance. The upper portion of the pituitary is usually flat or convex in shape; the infundibulum can be appreciated, as well as the optic chiasm superiorly. An adenoma is usually a hypoenhancing mass within the pituitary gland itself (see Figure 9.1). If it is not contained within

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FIGURE 9.1   Magnetic resonance imaging (MRI) of the brain in coronal (left) and sagittal (right)

sections with IV contrast. A hypoenhancing pituitary adenoma is visible adjacent to the right internal carotid artery (ICA).

the gland and rises above the sella, it is often a macroadenoma. If it approaches the optic chiasm in size, formal Humphrey visual fields should be assessed and trended in follow-​up. Any suprasellar tumor, such as a nonfunctioning pituitary adenoma or craniopharyngioma, can cause hyperprolactinemia due to what is termed “stalk effect.” The mechanism for this is via compression of the infundibular stalk, which prevents dopamine-​induced inhibition of prolactin secretion or impaired production of dopamine by the hypothalamus.2 If the MRI is consistent with a macroadenoma and the prolactin is only mildly elevated (